Alcohol Stories: a lifecourse perspective on self-harm, suicide and alcohol use among men

Alcohol Stories: a lifecourse perspective on self-harm, suicide and alcohol use among men

6 August 2015

Researchers: PI: Amy Chandler, School of Social and Political Sciences, University of Lincoln

RA: Briege Nugent, School of Law, University of Edinburgh

Key findings

Alcohol was described as a common-sense, ‘normal’, but largely ineffective, response to mental health problems among men.

Alcohol emerged as an important part of suicide planning in some accounts. Non-fatal self-harm (external injuries and overdoses) were described as occurring with and without alcohol.

Alcohol use is described as a ubiquitous part of social and cultural life in Scotland, particularly for men. This may make maintaining abstinence a struggle. Men may be at risk of isolation if they stop drinking.

Men described antagonistic relationships with mental health services. This was related to drug and alcohol use and to gender identities.

Background

Alcohol use is associated with increased risk of suicide, though the relationship is complex. Alcohol use is directly implicated in around half of all completed suicides; and those who are alcohol dependent are more likely than those without alcohol problems to take their own lives (Sher, 2006). While the relationship between rates of alcohol use and rates of suicide varies at a national level, it is estimated that higher rates of deaths by suicide in Scotland are at least partly related to higher rates of alcohol misuse (Mok et al., 2012).

Men in mid-life, particularly those from lower socioeconomic backgrounds, or who are living with socioeconomic disadvantage, are more likely than other groups to: a) die by suicide; b) experience alcohol-related harm (Chandler, 2012; Wyllie et al., 2012). At the same time, alcohol use has positive meanings, and plays an important role in maintaining social bonds for men and women in mid-life (Emslie et al., 2013). To date, there has been limited attention given to the rich and complex cultural meanings that alcohol use, and self-harm or suicide, have for men.

Methods

Alcohol Stories piloted the use of life-story methods with a group of men who had all experienced self-harm or suicidal thoughts/actions, to ascertain the viability of generating qualitative data addressing alcohol use, self-harm and mental ill-health across the lifecourse. The following research questions were addressed:

How, and in what ways, do men talk about alcohol use in relation to their life history?

How, and in what ways, do men talk about alcohol use in relation to mental health, self-harm and suicide?

Is the life-grid an appropriate research tool to investigate these issues?

A sample of 10 men aged 38-61 were recruited through two community mental health services. The sample was chosen in order to reflect a range of experiences with alcohol, whilst holding constant some experience of self-harm or suicide, gender, and age.

Participants took part in an in-depth largely unstructured interview with the lead researcher. An adapted version of the lifegrid was used, to give participants some structure through which to talk about their lives; and to underline the research interest in accounts of alcohol use across the lifecourse. The lifegrid is a tool which provides a structure for life-story interviews, providing chronological age across the horizontal axis, and themes along the vertical axis.

Interviews lasted between 1 and 2.5 hours, were digitally recorded and transcribed verbatim. Analysis was carried out by the researchers and drew out common and recurring themes across each interview, and the whole sample.

All men gave informed, written consent and were assured of their anonymity and their right to withdraw from the study. The research was approved by the University of Edinburgh’s Centre for Population Health Sciences Research Ethics Committee.

Findings

Alcohol, emotions and mental health

The use of alcohol to ‘cope’ or mask depression, anxiety and stress was a common narrative, even among men who reported no problem drinking. Some men associated the use of alcohol in this way with men in particular.

“But yeah, I don’t know, for the alcohol and stuff like that, it does go hand-in-hand with men and suicide. It’s weird. But like I say, that’s what people do, isn’t it? Go to the pub with their problems, drink as much as they can, and then when they leave you’ve got that poor me attitude on, I’ve got nothing, nobody loves me, who can I talk to? Can’t talk to my mates. F*** it, I don’t want to be here. And that’s what happens.” Tom

Alongside this, there was a general understanding that using alcohol in this way was ultimately ineffective and futile. Thus, while drinking alcohol in response to problems was ‘what people do’, there was a clear counter narrative that this approach did not work:

“So it’s like a vicious circle; you’re depressed and then you drink, and when you’re drunk you get even more depressed kind of thing. And what first started is having a drink to help you cope just made things worse after that.” Stevie

While participants with and without alcohol problems were able to acknowledge that alcohol use was an ineffective response to mental ill-health, this did not always translate into a commitment to abstinence. These tensions emerged in complex ways for men. Some emphasised that they could now ‘control’ their use of alcohol. Others indicated that despite ‘knowing’ that alcohol did not help; drinking was particularly difficult to avoid when experiencing mental ill-health:

“[AC asks if it is harder to avoid drink when N is depressed] Without a doubt. And especially, like, the run up to Christmas, things like that. They’re all depressing. And it’s hard. And you just drink…it’s not…I…it’s not ‘cause you want to have a drink, it’s just ‘cause you’re lonely sometimes and depressed and…that’s what it…that’s what I do.” Niall

Niall associated drinking with loneliness, a feature of several of the other accounts. In these cases, drinking – whether alone or with others – emerged at least as a temporary fix for such feelings.

Alcohol use, suicide and self-harm

Associations between alcohol use, suicide and self-harm were highlighted in two key ways by participants. Alcohol was described by several men as being an important part of planning suicide.

“…there will be people who, ken, directly link things like drink and suicide and they might feel suicidal, they’ve been drinking. And if they hadn’t been drinking, they wouldn’t have done it. But that’s maybe, but my opinion on that is that they may have been suicidal and then had the drink and it’s just given the courage to do it.” Mike

Some research suggests that alcohol is more likely to be present in male suicides than female suicides (Bilban & Škibin, 2005). As such, narratives which tie together ‘courage’, alcohol use, and planning suicide may be important in understanding this potential relationship.

Several participants reported taking overdoses, or cutting themselves, when drinking. Within these accounts, there appeared to be a distinction between overdoses which were framed as suicidal; and cutting which was aimed at expressing or managing anger or anxiety. Here, Paul contrasts an overdose with self-cutting:

“It never did the right away job. It was like I say, I woke up I thought, oh, I’m a bit rough because I’d been drinking. I went to work in the morning. Yeah, so…didn’t work, never worked, they did something, and then I’m glad to say, when I cut, always it would just be when I drank […] Tried it a few times when I was sober, but it hurt too much […] If I get that angry I’m, yeah, tempted again, but then I thought, no, I think I need a drink in me, so that’s kind of…I would say it’s went away, so it was really on and off.” Paul

These diverse accounts indicate that more attention should be paid to the different ways in which alcohol use and self-harm can be used; as well as underlining the importance of attending to accounts of self-harm among men. This is a topic that has only recently begun to be addressed in literature, which has historically focused self-harm among women (Inckle, 2014).

Managing or stopping alcohol use

Most participants provided accounts which emphasised that they had stopped, or reduced, their use of alcohol. This narrative drew on the understanding outlined above that alcohol was an ineffective response to mental health problems; and may indeed exacerbate them.

Of those who presented themselves as either mainly or totally ‘abstinent’, many related this to a ‘turning point’(Teruya & Hser, 2010). In most cases this was a physical health event – injury or illness – which led to medical advice to stop drinking. In these cases, men described ongoing challenges in maintaining abstinence, particularly given the ubiquitous role of alcohol in social life.

“And of course when you’re growing up, late teens, early 20s, that’s all your pals want to do, is go to the pub. By that time I’ve realised I’ve had an issue with it and then you can’t very well say to them do you mind if we just don’t go to the pub or something. You either go or you don’t, simple as. I’d rather be on my own sitting in the house than go with them.” Stevie

Men and health services

Participants reported a number of challenges faced when trying to access mental health services; in some cases, attempts to seek help were framed as being thwarted by substance use.

“… there was another time where I’d been really struggling for a few days and I’d been off the drink, I was really, really struggling, and I wanted to sign myself back into [rural psychiatric unit] and to give myself Dutch courage I had a drink, and then when I got up there they didn’t accept me because I’d been drinking.” Stevie

Others spoke more generally of facing difficulty in having their distress taken seriously, or responded to therapeutically rather than punitively. This issue was complicated, as several participants’ life stories were characterised by violence against others, as well as against themselves. Further, even among men who did not report violent behaviour, participants reported responses from services which implied that men’s distress might be more readily interpreted as aggressive and posing a risk to others, rather than themselves.

“And I said, ‘have you not got ten minutes?’ – ‘no, you’ll have to make another appointment’, as she’s driving away. I said, oh well f*** off then. And she reported me for that. She went back, because I got a letter saying that they were…because of my language, and she felt threatened!” Lewis

Use of the lifegrid

The lifegrid garnered mixed results among participants. As anticipated, some men chose not to use the grid at all, and had their own ‘stories’ that they preferred to tell without the aid of the grid. Other participants engaged superficially with the grid, and it did not feature heavily in the interview. One participant chose to fill out the grid himself, and in this case the grid did appear to help structure the interview. However, the grid does encourage a linear structure to participants’ stories, and this was not always appropriate. Further, some participants were uncomfortable with the unstructured nature of the interviews, and preferred to be asked specific questions, rather than setting the agenda themselves.

Implications and Conclusion

This was an exploratory study, and as such the above findings are indicative and tentative. Nevertheless, important themes emerged from men’s accounts of alcohol use, mental health, self-harm and suicide. These findings underline the need for further qualitative research which addresses the complex ways in which alcohol use intersects with mental health, and is shaped by gender identities and gendered practices.

Further research should attend to the way in which men, women, and non-binary gendered people, account for alcohol use and mental health across the lifecourse. Such research is particularly warranted given the increasing acceptability of drinking among women as well as men, and the continued central role of alcohol in British social life. Research should also endeavor to explore these issues among those who are not engaged in formal services.

The lifegrid may offer one way of conducting such research, but future research should test the use of more diverse, participatory methods through which to engage research participants. The grid may work more successfully if used alongside semi-structured interview questions.

This study points to the need for further qualitative investigation of the meanings that self-harm – whether ‘suicidal’ or not – has for men, as well as women. Several participants in this study highlighted that they had not disclosed their practice of self-harm outside of the research interview, which offers support to the theory that male self-harm is particularly under-reported.